Policy Development

Policy Development

   You are the operations director for Regional EMS, a medium-sized EMS service, enjoying an otherwise unremarkable day when one of your medics comes into the office with a complaint. It seems his partner likes to go shopping while they are on duty. When you question the partner, his response is simple: "We don't have a policy against it." You think about this for a few minutes and realize that, although you lump this particular circumstance into the "common sense" area, your EMS agency doesn't actually have a written policy about it. So, you sit down at your computer and draw up the "Agency Policy" template, pondering all the circumstances you can fix with this simple piece of paper. As you write all the possible outcomes, you wonder, "Will this actually fix the complaint, or am I just responding to a situation in an effort to cover my decision-making process?"

   EMS agencies need a variety of written policies to deal with the various operational and administrative issues that will certainly arise in their day-to-day operations. These policies will run the gamut from mutual aid issues to time/attendance, and should encompass events such as needlestick injuries, vehicle accidents and injuries in the line of duty.

   Since each EMS agency is somewhat unique, there is no standardized "model" policy. In this article, we will provide suggestions for items we believe EMS services should consider when developing service-specific policies and procedures. In some instances, your service will need to interact with, or obtain guidance from, other agencies and organizations in order to develop the necessary policies. Assistance, information and/or guidance should be sought from your EMS agency medical director, county EMS coordinator, hospital EMS liaison, regional EMS authority, agency attorney, insurance company, and others.

   It should be noted that policies, however necessary, are not the end-all of each agency and in no way absolve the manager from actively managing the agency. They should not be used to excuse or dismiss questions, comments or issues from staff requesting clarification of operational rules.


   Webster's Dictionary defines a policy as "a definite course or method of action selected from among alternatives and in light of given conditions to guide and determine present and future decisions or a high-level overall plan embracing the general goals and acceptable procedures especially of a governmental body."

   So what makes policy? The answer, according to Webster's, is "any action by management that changes or guides a course of action." That being said, some of the more common policy terms used in EMS are: SOG (standard operating guideline), SOP (standard operating procedure), memos, verbal orders, TO (technical orders), OI (operating instructions) and past precedence. Each of these, if implemented globally, is considered policy; therefore, when authoring any of these forms of communication, be extremely alert to the nature and long-term repercussions of their action.

   There are two basic types of policy: operational and administrative. Each serves a valuable function to an EMS organization. Administrative policies govern all aspects of how an organization operates "behind the scenes." A policy that requires all levels of personnel to provide a copy of a valid EMT or paramedic certification and a BLS HCP or ACLS card each year would be considered an administrative policy. Additional examples of administrative policies include, but are not limited to: how many hours a week a part-time employee can request, how many hours of continuing medical education (CME) are required to stay current, or how the board of directors is elected and for how long.

   The majority of street-level EMTs and paramedics will deal with operational policies. These are important because, simply stated, they govern how you do your job. Operational policies guide everyday operations and can be a bone of contention among coworkers and management, because not everyone does the same job the same way. This is where the manager has to be very careful not to create policy just to deal with individual situations. Examples of operational policies include, but are not limited to: minimum staffing for a given shift, operation of agency vehicles, crew makeup (EMT/EMT or EMT/paramedic), equipment logging, as well as narcotics administration and tracking.


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   Policy development for EMS agencies is often misunderstood and is a topic most managerial and administrative staff are less than comfortable with at times. There are some rules that should guide EMS policy-makers. Rule 1 in policy development is: Only develop policies that are absolutely needed in your organization. A good place to start is contacting your state department of health office of emergency medical services to find out which policies you must write in order for your EMS agency to operate within that state. The second authority you will want to contact is the state department of labor because, whether you are volunteer or career, there are certain regulations your state operates under concerning fair labor acts. After that, your medical control authority will have already written some policies and guidance that will help you develop your practice.

   Each policy should be individual and identified by subject/topic. It is important to develop a catalog or numbering system for organizing your policies. For example, the first policy written this year might have the following catalog number: 2010-01 (YYYY-##); subsequently using 2010-02, 2010-03 and so on will allow for easy reference and enables anyone to quickly search all service policies for specific items. The purpose and name of the specific policy should also be indicated. Many times policies are put in place but never reviewed or revised. By dating the policy, everyone will know when it was written and implemented. This allows the organization to set up a review process to ensure all policies are meeting its current needs. It may be beneficial to assign annual review of the organization's policies to a committee or officer.

   Individual policies should be detailed enough to cover everything that is expected of the employee/member and allow each to understand their responsibilities and actions.


   Policies are written in black and white: There is a circumstance and a result. However, a wise mentor once said, "You live by the SOPs or you will die by the SOPs." What he meant is that policy implementation is a gray area--much grayer than most people think--and policies are a guideline to management, not a substitute. How often is "Well, that's what the policy says" used as an excuse for not addressing a true issue? Policies are not shields for managers to hide behind, but rather a framework for decision-making in context. Let's look at a common example:

   Most agencies have a working hours policy that specifies when people must show up for work, how early they can come in and how late they can stay after completing their shift. Some even address situations that will excuse employees from discipline if they are late to work. Say ABC EMS Agency is located in Newburgh, NY, and there is a major snowstorm overnight. No winter warning caused you to set your alarm for an earlier time, so you awake to two feet of snow, which extends your travel time and you are late for work. ABC EMS Agency's policy says that "Disciplinary actions will not be taken under extenuating circumstances."

   There is a fundamental issue with the policy as stated above. First, the policy statement doesn't say specifically what extenuating circumstances are. In this case, an unexpected snow-storm would constitute an extenuating circumstance; however, it is left up to the supervisor/manager on duty to make that decision. The issue is that it is not objective, therefore, a number of other factors could and often do influence whether the employee gets disciplined instead of taking this issue as a singularity. Developing a list of extenuating circumstances seems like a good idea; however, the way it is written into policy will dictate its usage. Use terminology like "Extenuating circumstances include but are not limited to: environmental factors, family emergencies, abnormal traffic patterns, etc." The first part clearly allows the supervisor/manager to use good managerial skills within a certain framework to make a decision.

   We believe what the mentor mentioned above was trying to say was that managing is decision-making, not solely following a set of predetermined rules. Following policies to the letter will no doubt ensure consistency, but what will it do to morale? Managing is making choices. If you remove the supervisor/manager's ability to choose, you're saying you don't need him; that you can effectively run the organization with robots.


   Policy development is difficult and may take many attempts to perfect, so it helps to have a good starting point. Try implementing the policy from many different perspectives by asking, "What are the consequences of this policy on morale, staffing, finance and operations?"

   Taking time to forward-think policy development will go a long way to untangling the bureaucratic red tape in which organizations often find themselves when they use policy instead of good strategic thinking and management techniques.



   The title is fairly straightforward. It is a simple definition of the policy being presented, such as "Minimum Staffing Standards for ABC EMS Agency."


   This defines to whom or what sections the policy applies. One example could be, "This policy refers to the minimum number of qualified EMTs and paramedics required on a given shift. All personnel who operate in a prehospital care capacity with ABC Agency must adhere to this policy."


   This gives specific reason and rationale to the policy, as well as the reason for its development. It encourages the author to thoroughly review the reason why this policy is being written and if it even needs to exist.


   This is the meat and potatoes of the document, where its actual direction is stated in a clear and concise manner that is objective yet easy to read. The key to policy development is to only write what is absolutely necessary. Try to keep the "fluff" out. Each statement should be very direct and to the point. This means:

  • Ensuring that there is enough detail to allow members/employees to understand the scope of the policy and required actions.
  • Designating a responsible individual/group for maintaining and updating the policy. If there is a specific group or person responsible, it needs to be in writing.
  • As a general rule, use positions and job functions for policy-specific actions, rather than specific names. For example: "The QI Coordinator will review all charts dealing with cardiac arrests on a weekly basis"--not "John Doe will review all charts dealing with cardiac arrests on a weekly basis."


   When an associated process is defined in the policy section, a procedure must be developed to carry out the policy. The procedure standardizes the way a specific task is completed each time and provides a measuring tool to ensure policy compliance. Procedures can be dictated through steps or checklists.


   Time-stamping all actions regarding the policy allows for an accurate history and timeline of the evolution of the policy.


   Any citations used in policy development should be put in this section in case readers want to gather more information about the topic. This includes relevant local, county, regional, state and federal documents and/or policy guidance.


   Some policies require regular review dates. If there is a cycle or pattern, it must be stated clearly and follow-up dates need to be included in the appropriate "updated" block, as stated above.


   Although you should be evaluating and developing each policy with input from multiple perspectives (line, supervisory and management personnel), after it has been developed, it should be evaluated by your corporate counsel prior to being distributed and implemented. Even after it has received an attorney's seal of approval, rolling out policy to your line personnel must be a deliberate process involving a method of dissemination (this can include fax and/or e-mail), as well as a method for actually ensuring personnel and their supervisors understand the policy (this can include an in-service or even a DVD informational session). It goes without saying that all employees who receive any new or revised policies should be required to sign off that they received and understand the policies.

   Don't discount the fact that written policies provide liability to management. If your governing body, such as a council or board of directors, approves a policy, the liability for actions taken under that policy falls on them. This is especially serious when the governing body chooses not to be an active part of the organization--or serves as a rubber stamp, if you will. The highest authority in an organization is ultimately responsible for all actions of the members operating under them.

   Raphael M. Barishansky, MPH, is program chief of public health emergency preparedness for the Prince George's County (MD) Health Department and a member of EMS Magazine's editorial advisory board. Contact him at rbarishansky@gmail.com.

   Daniel E. Glick, BPS, NREMT-P, is the coordinator for emergency programs at Schenectady County (NY) Community College and an aeromedical evacuation operations officer for the 139th AeroMedical Evacuation Squadron, New York Air National Guard. Contact him at deg3142@gmail.com.

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